HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 83 ACADEMY ROAD 10/21/2019 K
Commonwealth of Massachusetts
-- City/Town of NORTH ANDOVE ,MASSACHUSETTS,
- System Pti ping Record
Form 4
DEP has provided this form for use by local Boards of Health, Tha System Pump°ng Record must
be submitted to the local Board of Health or other approving autho7ity.
A. Facility Information -
Important:
When fining out 1. S ern Location:
forms the (1 �Q
computer,use VVV
only the tab key Address
to move your North Andover MA 01845
cursor-do not City/Town State Zip Code
use the return
key" 2. System Owner: j
b V.AA,W SLe ofo-j S
Name
'- Adl Address(if different from location)
City/Town State n, —7 n 6 ode S�N
Telephone Number
B. Pumping Record
r�
1. Date cf Pumping Date S 2. Quantity Purnped: Gallons �
3. Type of system: ❑ Cesspoei(s) [�I'Septic Tank ❑ Tight Tank
❑ Other(describe): ---- --
4. Effluent Tee Filter present? ❑ Yes 2r No If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
K
6. System Pumped By:
Name Vehicle License Number
Wind River Environm6ntal
Company
7. "Location where contents were disposed:
I. W T.P
Ipswic MAi
Signature of Hauler Date
http://www.mass.gov/dep/water/approvalsit5forms.htm#inspect
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